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1. DECEDENTS -NAME (First, Middle, Last, Suffix) Roy Dean Fredrickson 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Loyalton, South Dakota 7. SOCIAL SECURITY NUMBER 725 -10 -3813 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 1 8d COUNTY OF DEATH Hall 9a, RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9d. STREET AND NUMBER 2219 Cochin St. 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Oscar Fredrickson 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 11/28/1951- 11/27/1953 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation IE Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) in death) 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? ❑ YES ❑ NO 22b. TIME OF INJURY 5a. AGE - Last Birthday (Yrs.) 85 23a. DATE OF DEATH (Mo., Day, Yr.) W September 30, 2015 �E F 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH W ; October 2, 2015 04:03 PM U Z q 0 3d. To the best of my knowledge, death occurred at the time, date and place G and due to the cause(s) stated. (Signature and Title) f William Landis, MD ❑ YES Ea NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print William Landis, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 1 28a. REGISTRAR'S SIGNATURE A.. 5b. UNDER 1 YEA - . MOS. DAYS HOURS 8a. PLACE OF DEATH HOSPITAL ® Inpatient ❑ ER/Outpatient ❑ DOA QTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 9c. CITY OR TOWN Grand Island 9e, APT. 0. 2. SEX Male 5c. UNDER 1 DAY MIN$. 9f. ZIP CODE 68801 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Genevieve Barbara Voeller 12. MOTHER'S -NAME (Fi t, Middle, Maiden Surname) Anna Loveland 14a. INFORMANT -NAME Genevieve Barbara Fredrickson 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENS NO. 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 3. DATE DF (Mo., Day, Yr.) SApteulber 30, 2015 '6. DATE OF BIRTH (Mop, Day, Yr.) February 1, 1930 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) October 2, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CI / TOWN Central Nebraska Cremation Services Giabon STATE Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examales) 18. PART 1. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add ad IMMEDIATE CAUSE: a) Metastatic Carcinoma Of Thyroid IMMEDIATE CAUSE (Final disease or condition resulting s cardiac arrest, itional lines if necessary. APPROXIMATE INTERVAL onset to death 4 Months Sequentially list conditions, if any, leading to the cause listed on line a DUE TO, OR AS A CONSEQUENCE OF: b) onset to death Enter the UNDERLYING CAUSE (disease or injury that initiated the events resulting In death) LAST DUE TO, OR AS A CONSEQUENCE OF: C) onset to death DUE T0, OR AS A CONSEQUENCE OF: d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underiyin cause given In PART 1. Ischemic Heart Disease With Coronary Bypass 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPOR ❑ Driver /operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) ATION INJURY 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSID =RED? YES NO 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES NI NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, fact ry, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 24a. DATE SIGNED (M ., Day, Yr.) 24b. TIME OF DEATH 24c. PRONOUNCED D AD (Mo., Day, Yr.)I 24d. TIME PRONOUNCED DEAD 24e, On the basis of exami the time, date and pi ation and/or investigation, In my opinion death occurred at ce and due to the cause(s) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? gl Not Applicable if 26a Is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 5, 2015 1 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMEN OF HEALTH AN' tiUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH T E NEBRAS A ""DEP4 1-14, /VT pF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITO "Y FOR- FOR-VITAVadb S, k DATE OF ISSUANCE STANLEY S, COOPER • ASSISTANT STATE REGISTf2AA DEPARTMENT OF HEALTH, AND' LINCOLN, NEBRASKA HCIMAN SERVICES • 10/09/2015 STATE OF NEBRASKA 201606137 OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMA SERVICES CERTIFICATE OF DEATH 15 05742